Traumatology

1. D Generally, following hemorrhage in humans, a rise in osmolality is directly related to the glucose concentration in the plasma, not the result of an influx of sodium. All of the other statements are true. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1467-1470.)

2. C Catecholamines produce hyperglycemia, hyperlipidemia, increased oxygen consumption, and hyperkalemia, and a-stimulation reduces insulin and glucagon secretion. The overall effect of catecholamines on the islet cells it to not only increase glucagon, but also decrease insulin secretion. Cortisol decreases the peripheral utilization of glucose but the increase in plasma cortisol is designed to produce an increase in osmolality in response to hemorrhage. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1470.)

3. T, T, T, F, F, T, T Angiotensin II is a powerful vasoconstrictor. Aldosterone works on the ascending loop of Henle and in the collecting ducts of the kidney to increase sodium and water absorption. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1470-1472.)

4. C An attempted open-operative cricothyroido-tomy may cause irreversible damage to the larynx. All of the other statements are true. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1474-1476.)

5. B, A, C Hydroxyethyl starch, albumin, and lactated ringers are commonly used fluid replacement solutions. Their physical properties differ and may affect selection. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1481,1482, table 43.5.)

6. C Almost all plasma coagulation factors are stable in banked blood, with the exception of factor V and VIII. With massive transfusion, defined as greater than 2 blood volumes in a child, hemostatic defects may occur as a result of dilution or a decrease in the platelet and circulating protein coagulation factors. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1482,1483.)

7. C In Weil's 5-2 or 7-3 rule, the 5-2 applies to the central venous pressure (CVP), and the 7-3 rule applies to the pulmonary capillary wedge pressure (PCWP). Volume boluses are administered and the pressure response is measured. When the CVP is less than 8 or the PCWP is less than 12, 10-20 mL/kg of isotonic solution is infused over 10-15 minutes. If the CVP increases by more than 5 or the PCWP increases by more than 7, the infusion is stopped. Immediate fas-ciotomy is indicated when a pressure greater than 60 cm H2O is present. Cardiac tamponade presents with paradoxical pulse and hypotension. A pulmonary hematoma takes only a few days to resolve. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1485-1490.)

8. F, T, T, T, F, T, F, T, T The rupture is more likely on the left because of the presence of the liver on the right acting as a cushion to the diaphragm. Pulmonary compliance decreases with adult respiratory distress syndrome. An intravenous pyelogram is indicated for gross hematuria with clinical evidence of renal injury and unstable clinical course of blood loss and a possible renal artery injury. (Rogers MC, et al.

Textbook of Pediatric Intensive Care, 3rd Edition; pp.

1491-1495.)

9. B Loss of consciousness of 3 minutes or more is an indication for a skull film. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1495, table 43.7.)

10. E There is a decrease in the perfusion, which results in the initial ischemic insult to the spinal cord following trauma. All of the other statements are true (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1496.)

11. T, T, T Please see Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 65, 1498, and table 2.10.)

12. B Child victims of abuse are usually younger than 2 years of age. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1498, table 43.8.)

13. E Hypertension is a commonly described phenomenon associated with thermal injury. The increase in plasma renin activity and aldosterone increases intravascular volume and raises blood pressure. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1522.)

14. E Pulmonary dysfunction after thermal injury may be secondary to inhalational injury, aspiration, shock, sepsis, congestive heart failure, or trauma. The presence of inhalational injury increases mortality by 20%, whereas pneumonia increases the risk of mortality by 40% in burn patients. In the resuscitation phase of burn injury, lung injury results from hypoxia and subsequent reoxygenation, CO and cyanide toxic-ity, airway edema, chest wall, and pulmonary compliance problems. Hypoproteinemia may contribute to edema formation in the postresuscitative phase. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1522.)

16. C, D, A, D C, C, A, B Renal blood flow decreases immediately after injury. Later, GFR increases coinciding with the onset of the postburn hypermetabolic state. Hepatic dysfunction is commonly encountered in thermal injury, and can generally be found in more than 50% of patients. Thrombocy-topenia appears first, then is followed by thrombocytosis several days later. Significant increases in fibrinogen, Factors V and VIII occur. RBC mass decreases. Hypoxia occurring in the first 48 hours was the most common cause of encephalopathy and was related to smoke and CO inhalation sustained in enclosed fires. Acalculous cholecystitis is of two types in the burn patient. The first involves bacterial seeding in septic patients and the second arises in patients with dehydration, ileus, or pancreatitis in whom the gallbladder is distended with sterile fluid. Burn-injured patients are immunocompromised. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1522-1525.)

First-degree burns are superficial burns isolated to the epithelial cells and characterized by erythema and mild blistering. Second-degree burns involve a tissue depth into the dermis. A superficial partial-thickness burn is moist, red, and tender. It becomes pale, but dermal papillae can be visualized through the eschar within a few days. Third-degree burns extend through all layers of the skin and invade the hypodermic fat. Fourth-degree burns involve deep injury to bone, joint or muscle. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1525-1526.)

17. B With the Rule of 9's, the front and back are each assigned 18% of BSA; each arm is assigned 9%; each leg is assigned 18%. Therefore, a burn that involves 9% (arm), plus 18% (leg), plus 18% (back), equals 45% total BSA burn. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1526.)

18. B, C, A A minor burn involves less than 5% of the BSA and no significant involvement of the hands, feet, face, or perineum. A moderate sized burn involves between 5 and 15% of the body surface area. Alternatively, any full-thickness component also qualifies. Involvement of the hands, face, feet, perineum, or the presence of a complicating factor, such as chemical or electrical injury, also constitutes a moderate burn. A severe burn is characterized by more than 15% total BSA burn or the presence of smoke inhalation or CO poisoning. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1526, figure 45.2.)

19. B House fires account for 84% of burn associated fatalities, the cause of which is most frequently smoke inhalation rather than tissue damage from flames. Chemical burns should be flushed with water for 20-30 minutes, not alcohol. Tetanus prophylaxis must be addressed in all burn patients. Scald burns are the most common type of pediatric burn and the home is the most common location. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1526,1527, table 45.1.)

20. E The criteria for transfer to a burn center include significant underlying disease, associated inhalation injury, 10% BSA or more of partial or third-degree burns in children younger than 10 years of age or more than 20% BSA in children older than 10 years of age, third-degree burns more than 5% in any age group, electrical and chemical burns, and burns associated with major trauma. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1527,1528.)

21. T, F, T, T, T Systemic blood pressure is usually maintained after thermal injury despite hypov-olemia, thereby making blood pressure an insensitive measure of volume status. Generally, children with less than 5% of their BSA burned do not require intravenous fluid therapy. Children with a burn exceeding 15% BSA will require intravenous resuscitation. If the burn size exceeds 30% BSA, placement of a central venous catheter is recommended. Muscle relaxants and sedation are contraindicated in the child who has signs of upper airway obstruction up until the airway is secured. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1528.)

22. B, A, E, B, B Mafenide is an excellent antibacterial. It inhibits carbonic anhydrase and may lead to acidosis. It can be painful, but penetrates the eschar rapidly. It is applied twice daily. Silver sulfadiazine is a broad antibacterial agent that is painless. It penetrates fairly well through the eschar. It is contraindicated in pregnancy and has unknown absorptive properties in the fetus. Bacitracin is limited in its antibacterial action, has poor eschar penetration, but is easy to apply and cosmetically acceptable. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1530, table 45.2.)

23. D The Parkland formula recommends lac-tated Ringer's solution in the first 24 hours postburn in the amount of 4 mL/kg/% BSA burn. One half of this volume is given in the first 8 hours postburn and the remainder given over the remaining 16 hours. The resuscitation should be adjusted to maintain a urine output of 0.5-1.0 mL/kg/hour. On the second postburn day, maintenance fluid of a glucose-containing hypotonic fluid may begin. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1529.)

24. T, T, F, F, T Resistance to silver sulfadiazine is common for Enterobacter cloacae, S. aureus, and occasionally P. aeruginosa. All three of these organisms are usually sensitive to Mafenide. Silver nitrate can induce methemoglobinemia. Ideally surgical excision and closure of the wound should take place as soon as the child is stable enough for anesthesia. More than 105 organisms per gram of tissue constitute burn wound sepsis. Early surgical closure decreases significant blood loss. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1530-1531, table 45.2.)

25. E An adverse effect on the immune function may occur if lipid content is more than 15% of total diet kcals particularly if it is high in the ffl-6 fatty acids. Enteral feeds prevent hypermetabolism and catabolism in contrast to parenteral feeds. Positive nitrogen balance may be achieved earlier with the institution of enteral nutrition within the first 4 hours. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1531-1532.)

26. E Thermal injury from smoke inhalation is usually limited to the supra-glottic airway. Inhalation injury accounts for more than 50% of the mortality associated with major burns. Carbon monoxide poisoning accounts for approximately 50% of the poisonings in the United States per year. The largest source of CO is generated from the incomplete combustion of carbon-containing compounds. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1534-1536.)

27. D The oxy-Hb dissociation curve is shifted to the left in CO poisoning, thereby enhancing oxygen affinity for Hb and impeding oxygen delivery from blood to tissue. The toxic effects of CO result from its direct action on the cytochrome-oxidase system and not solely on the reduced oxygen carrying capacity of the blood. If a significant amount of time has passed since the exposure of CO poisoning, an abnormal level may not be discovered. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1534-1536, figure 45.4.)

28. D The heart rate and coronary blood flow increase in response to CO. Pulmonary edema occurs in about 10-30% of cases, however, the mechanism for pulmonary edema remains speculative. Cerebral blood flow and edema also increase. The cherry-red skin color is not commonly seen clinically. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1534-1536, table 45.4.)

29. T, F, F, T, T, T, T, T Muscle necrosis leads to myoglobinuria and subsequent acute renal failure. Salivary amylase is responsible for development of hyper-amylasemia. A mild acidosis actually shifts the oxy-Hb dissociation curve to the right, increasing release of oxygen to the tissues and so should not be treated. The half-life of CO is 5-6 hours in room air, 1.5 hours in 100% FiO2, and less than 30 minutes in 100% FiO2 in 2.5 atmospheres. Hyperbaric oxygen treatment should be instituted when a patient has a CO Hb of more than 25%, signs and symptoms of CO poisoning, and a hyperbaric oxygen facility available. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1534-1538, table 45.5, 45.6, and 45.7.)

30. C, A, B CO concentrations affect the presenting symptoms. A CO Hb concentration of more than 0.195 is rapidly fatal, a CO Hb of 0.022 is associated with disturbed judgement, and a concentration of 0.007 is associated with shortness of breath with vigorous exercise. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1537, table 45.5.)

31. E Cyanide poisoning from smoke commonly occurs and acts synergistically with CO toxicity. Smoke injury decreases ciliary function. Patients with pulmonary injury may be asymptomatic with a normal chest radiograph on presentation. Arterial blood gases may also be normal for the first 12-24 hours. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1539.)

32. D At low voltages, alternating current is more dangerous than direct current because of its ability to freeze the extremity to the electrical source. Joule's law states that power equals amperage squared times resistance (P = I2R). Surface burns result from the ignition of clothing or from the heat of the current traveling close to the skin. Arc burns are produced by a current that travels external to the body, as an electric arc forms between two objects of opposite charges. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1540.)

33. F, T, T, F, F, F, T Water content and a thinner stratum corneum decrease skin resistance in children. The conducting system of the heart is particularly vulnerable and ventricular fibrillation can occur with a current of 100 mA passing through the chest. Transient arrhythmias are present in 30% of patients. Tetanic spasms of respiratory muscles occur at 30 mA. Neurological findings are common. Loss of consciousness, spinal cord lesions, deafness, seizures, and changes in mood commonly occur after electrical injury. Nearly two-thirds of people struck by lightning live. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1541.)

34. A CO2 autoregulation is better maintained than blood pressure autoregulation.

35. D When using uncrossmatched blood, it is best to obtain at least an ABO and Rh type and partial crossmatch. This is sometimes referred to as an incomplete or partial crossmatch. The immediate phase cross-match eliminates serious hemolytic reactions because of errors in the ABO typing. It will fail to detect only a few unexpected antibodies outside of the ABO system, most of which are clinically insignificant. If time does not permit even a preliminary screen, ABO and Rh type-specific, uncrossmatched blood is still preferable (and more abundant). Of patients never exposed to blood, fewer than 1 in 1000 will have an unexpected antibody detected in the immediate phase crossmatch. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1482,1483.)

36. E FFP provides the equivalent clotting factors of a single unit of fresh whole blood. The administration of FFP should be considered when 200% of the calculated circulating blood volume has been replaced with crystalloids and red cell concentrates. A precipitous fall in platelet count may not be tolerated, as well as a slow decline in thrombocytopenic patients. Platelet administration begins when 100-150% of the calculated circulating blood volume has been replaced with crystalloid and red cell concentrates. The dilutional coagulopathy is rapidly corrected once perfusion is restored, but may be exacerbated by the development or persistence of hypotension. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1483.)

37. C Bleeding and edema within an intact fascial compartment can lead to the development of increased pressure, muscle ischemia, and death. Whereas pulses may be intact distally with a compartment syndrome, one constant finding is severe pain even with passive motion. Muscle compartment pressures can be evaluated during the secondary survey of the trauma patient using an 18-gage needle and water manometer. Compartment pressures of 40 cm H2O should cause concern, whereas pressures greater than 60 cm H2O require fasciotomy. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1486.)

38. C In addition to measuring urine output, the bladder catheter facilitates the diagnosis of urinary tract injury and rhabdomyolysis. An oral gastric tube should be placed in all patients with abdominal trauma. This procedure removes air from the stomach and improves ventilation, empties liquid and particulate matter, decreases the likelihood of aspiration, and provides diagnostic information concerning the presence of blood in the upper GI tract. If a pelvic fracture is suspected or seen on a radiograph, a rectal examination should be performed to evaluate the possibility of bone fragment injury to pelvic structures. Pain on passive range of motion is a constant finding in compartment syndrome. See response to question 37. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1485-1487.)

39. D Almost all deaths from thoracic injury in children occur after the victim reaches the resuscitation center, and most children can be treated successfully with prompt diagnosis and aggressive early management. Penetrating injuries to the chest are unusual in children and usually result from fractured ribs rather than from external missiles. The mediastinum of the child is more mobile and this contributes to a low incidence of major vessel and airway injury. However, serious intrathoracic injury may be present in the absence of obvious chest wall injury. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1487,1488.)

40. A Cardiac arrest from blunt chest trauma is nearly always associated with multiple system injuries, and results from hypovolemia either from external or internal blood loss. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1487,1488.)

41. D Flail chest injuries are rarely seen in children because high-velocity direct-chest trauma is uncommon. Additionally, rib fractures are less common in children than adults because children have very pliable ribs that are resistant to fracture. Contusions and/or penetrating injury of the lung parenchyma are frequently involved. The initial therapy should include humidified oxygen and a limitation of crystalloid resuscitation, if the remainder of the injuries permit, so that there will be a decrease in extravasation of fluid into the injured pulmonary parenchyma and a limitation of the secondary acute pulmonary edema. Definitive treatment of the flail chest takes place in the PICU by controlled ventilation and PEEP. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1488,1489.)

42. E The least common occult and potentially serious injury to the chest of a child with multiple trauma is esophageal rupture. From most to least common, the injuries are pulmonary contusion, pulmonary laceration, pulmonary hematoma, tracheobronchial tear, myocardial contusion, diaphragmatic rupture, partial aortic or great vessel disruption, and esophageal perforation. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 1489.)

43. C In the setting of pulmonary contusion, overhydration should be avoided because fluid will sequester in the damaged lung tissue and complicate the clinical condition. Radiographical evidence of a pulmonary contusion includes early consolidation of the lung parenchyma, which may be focal in nature, with resolution over 2-6 days. Empyema, or abscess formation, may occur after pulmonary contusion secondary to the extravasation of fluid and blood into the alveolar and interstitial spaces. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 1489,1490.)

44. E Drowning is the third most common cause of death by unintentional injury among persons of all ages in the United States, and the second leading cause of injury deaths in children younger than 15 years old. Males account for 78% of all deaths from drowning. Approximately 50% of the drowning deaths occur in the summer. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 875-877.)

45. E The majority of drowning accidents occur in the southern and western United States; Saturday is the most common day of the week for drowning accidents; private pools are the most common sites for submersion accidents involving children; and drowning rates are highest among the African-American population. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 875-877.)

46. T, F, T, T Drowning is death from asphyxia caused by submersion in water. Death usually occurs at the time of submersion or within 24 hours. Most human drowning victims aspirate less than 3-4 mL/kg of fluid. Fresh water causes surfactant to denature and become nonfunctional. Seawater either dilutes surfactant concentrations or washes the surfactant out of the alveolus entirely. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 875-881.)

47. E The pathophysiology of submersion injury can include the processes of asphyxia, fluid overload, pulmonary injury, and hypothermia with the diving reflex. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 878-883.)

48. D Therapeutic hypothermia has not been shown to improve outcome. A body temperature of less than 32°C causes the cessation of shivering. Resuscitation of drowning victims should continue until the core temperature is at least 32°C. Pupillary dilatation occurs at a core temperature of less than 30°C. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 882-889.)

49. T, F, T, T, T, F, F, T Chest radiographs do not correlate with clinical outcome. Steroids have not been shown to be useful in improving the outcome for ischemic or anoxic insults. Intracranial pressure monitoring has not been shown to improve outcome in submersion injury. PEEP is often useful in treating the pulmonary dysfunction that is associated with a near-drowning episode, which is unresponsive to supplemental oxygen. The drowning victim will often swallow a large amount of water, which may induce emesis and subsequent aspiration. Consciousness is then lost. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 878-889.)

50. E The EEG may not be reliable in very young and particularly premature infants, because there are reports of return of neuronal function and EEG activity after the demonstration of electrocerebral silence. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 896-899.)

51. D No corroborative testing is required in the case described. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 895-900).

52. A Stereotyped movement of the extremities and extensor posturing can be seen in patients who are clearly brain dead; these have been termed the Lazarus sign. Spinal and deep tendon reflexes are found on physical examination in at least 50% of brain dead patients. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; p. 902.)

53. T, T, T, T All of these statements are true. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp. 895-902.)

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